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Health Care Trends |
Americans’ Views On Health Policy: A Fifty-Year Historical Perspective
| Abstract |
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A review of data from more than 100 public opinion surveys conducted over a fifty-year period finds that the American public has conflicting views about the nation’s health policy. They report much dissatisfaction with the health care system and with private health insurance and managed care companies, and they indicate general support of a national health plan. However, most Americans remain satisfied with their current medical arrangements, do not trust the federal government to do what is right, and do not favor a single-payer type of national health plan. The review also finds that confidence in the leaders of medicine has declined but that most Americans maintain trust in the honesty and ethical standards of individual physicians.
For decades public opinion researchers have sought to learn what Americans think of a variety of subjects, including health care. We now have more than fifty years’ worth of historical trends on Americans’ views related to health policies. Understanding these trends is important for a number of reasons. First, public opinion influences the outcome of elections and often sets the health policy agendas of those seeking public office. Second, studies have shown that public opinion influences government decision making beyond election outcomes and often affects policy decisions made by Congress, the executive branch, and the United States Supreme Court.1 Examining Americans’ views on the same issue in different time periods helps us to understand better the changing nature of the health policy environment.
This discussion is divided into six sections, examining the public’s views on (1) national health insurance and the enactment of Medicare; (2) the U.S. health care system; (3) health care as a national priority; (4) confidence in health professionals and institutions; (5) satisfaction with one’s own health care; and (6) the role of government in general, as a context for health policy attitudes.
Sources of data. Despite the large number of polls conducted over the past five decades, relatively few have included questions asked with similar wordings so as to provide historical trends concerning public opinion on health policy issues. The data in this paper are restricted to those issues for which the same polling questions on a health policy issue were asked for three or more years.
The data presented here consist of specific results from more than 100 opinion surveys conducted nationwide between 1945 and 2000. We compiled these results from the POLL database at the Roper Center for Public Opinion Research in Storrs, Connecticut, from the Harris Interactive subscription service, and from published research papers containing particular historical data used in our trend series. These polls involved interviews with 500 to 2,000 randomly selected adults. In the years prior to 1985 most of the polls were conducted in person; after 1985 most were conducted by telephone.2
| National Health Care Reform |
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 Top National Health Care Reform Views Of The Health...Health As A National...Public Confidence In Health...Americans' Views Of Their...The Role Of GovernmentDiscussionNOTES |
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Since World War II there have been four major debates over reforming the nation’s health care system: (1) the late 1940s debate about President Harry Truman’s proposed national health insurance plan; (2) the 1961–1965 debate during the Kennedy and Johnson administrations over providing health insurance for elderly Americans (Medicare); (3) the 1971–1974 debate about President Richard Nixon’s proposed national health insurance program; and (4) the 1993–1994 debate about the Clinton administration’s health care reform proposal.
Trend data on public opinion are available for three of these four debates; only the Nixon-era debate has no trend data available. The data suggest that there were common features among these three national debates.
First, prior to the introduction of each bill, public interest in some type of national health care reform already existed. In the years leading up to the Truman proposal, 82 percent of Americans said that something should be done to make it easier for people to pay for doctor and hospital care, and 68 percent thought that it was a good idea for Social Security to cover doctor and hospital bills.3 Shortly before Medicare was enacted, 75 percent of the public said that the federal government should pass a law to provide medical care for seniors.4 During the year of Bill Clinton’s first election as president, 66 percent of Americans favored national health insurance financed by tax money—up from 46 percent in March 1980 (Exhibit 1
).5
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There were other similarities between the Clinton and Truman plans. After each plan was introduced and the policies were made explicit, opposing groups entered the debate and argued that the enactment of the proposal would result in a health care system worse than the existing one. In spite of the general support for a national health plan portrayed in Exhibit 1
, public support for the Clinton plan declined from 59 percent in September 1993 to 40 percent in July 1994.6 Also, the public became more negative toward the Clinton plan on the issues of too much government, the cost of the plan, limits on choice of doctors, and the quality of care available.7 A similar phenomenon occurred during the debate over the Truman plan. In March 1949, 38 percent opposed the Truman plan. By October 1950, after an extensive campaign by opponents, public opposition had risen to 61 percent.8 Only in the case of Medicare did the majority of Americans continue to support the specific national reform proposal after learning more about it. Polls at the time show 61 percent and 62 percent of the public supporting the proposed Medicare legislation in the fall of 1964, and 65 percent after it was enacted in 1965.9 The Clinton and Truman examples suggest the need for caution in interpreting poll results favoring national health care reform prior to the introduction of a specific proposal. Among the confounding factors is the lack of an underlying consensus among the American public over the preferred type of national health plan. Polls that offer only one plan as a possible solution often show majority support for that proposal. But when other major alternative proposals are offered, as they were in each of these two national debates, public support splinters.
In 1946, 1963, and 1993, when the public was given the choice of more than one type of national health reform legislation, none gained majority support. Of particular interest is that when proposals are introduced involving a major private-sector role, the option of a government health plan never achieves majority support from the public (37 percent in 1946, 42 percent in 1963 for the elderly, and 28 percent in 1993).10
Recent polling presents another example of this lack of consensus. In 2000, when asked in general about national health insurance financed by taxes, 56 percent of the public (54 percent of registered voters) said that they were in favor.11 But when a clause was added specifying that all Americans would get their health insurance from a single government plan, support fell to 38 percent of registered voters (Exhibit 1).12 This illustrates the lack of public consensus on what a national health plan financed by taxes should entail.
| Views Of The Health Care System |
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| TopNational Health Care ReformViews Of The Health...Health As A National...Public Confidence In Health...Americans' Views Of Their...The Role Of GovernmentDiscussionNOTES |
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Much of the efforts of health policymakers have been focused on improving aspects of the nation’s health care system. An important measure of public ferment for change in the health system is how satisfied Americans are with the current system and how much change they believe is needed.
One trend question assessing satisfaction with the health care system asks Americans if they think that our system works pretty well and needs only minor changes, has some good things but needs fundamental changes, or has so much wrong with it that we need to rebuild it completely (Exhibit 2).13 The first response implies satisfaction with the status quo, and the last response suggests a high level of public dissatisfaction and support for major change.
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By this measure, starting in 1982, the majority of Americans have never been completely satisfied with the health care system. Americans were the most positive in 1987, when 29 percent reported that they saw the system working pretty well. In 1991, often seen as the starting point of the great health care reform debate of the early 1990s, only 6 percent held this favorable view. In that year Democrat Harris Wofford won a special Senate election in Pennsylvania on a platform calling for national health insurance. In that same year 42 percent of Americans expressed the view that the health care system should be completely rebuilt, the highest level ever reported. By 2000 only 29 percent held this view. Taken together, this trend shows that most of the public has never been completely satisfied with the system during the past eighteen years, but never has a majority supported developing an alternative system.
In a second trend, starting in 1993, a majority of Americans has expressed dissatisfaction with the availability and affordability of health care in this country. However, the proportion who reported that they were not at all satisfied has declined from 45 percent in 1993 to 26 percent in 1997 and 27 percent in 2000.14
One last specific measure of the health system concerns the adequacy of the supply of physicians. In the post–World War II period, U.S. health policymakers have gone from having great concerns about shortages of physicians to concerns about a physician surplus. Over the past two decades the proportion of Americans who think that there are too few physicians in their community has declined, from 38 percent in 1981 to 28 percent in 2000.15 However, only 10 percent perceive a physician surplus in their community, and this figure has not changed in two decades. This suggests that if a physician surplus is developing, it is not yet visible to the public.
| Health As A National Priority |
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| TopNational Health Care ReformViews Of The Health...Health As A National...Public Confidence In Health...Americans' Views Of Their...The Role Of GovernmentDiscussionNOTES |
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Over the years a number of experts and commentators have expressed concerns about the high level of health spending in the United States. These concerns have not been shared by the general public. Since 1973 the majority of Americans has said that the United States is spending too little rather than too much on improving and protecting the nation’s health (Exhibit 3
).16
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The lowest levels of support for more spending occurred in 1978 and 1980, when national health care cost containment was being debated. The highest levels occurred in 1990 and 1993 during the debate over national health care reform. At no time in this quarter-century trend did more than 9 percent of the public feel that the nation was spending too much on health. The question wording is rather broad and is likely to include public support for increased spending on health care, public health, prevention, and/or medical research.
Although Americans may have continuously supported more spending on health, the priority for health spending and activity has fluctuated over time. Since 1993 Americans have been asked what they think should be the two most important issues for government to address (Exhibit 4).17 In January 1993, 31 percent of Americans selected health care (excluding Medicare) as one of these two issues. The high point in public priority for health care was in October 1993, again at the height of the health reform debate.
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| Public Confidence In Health Professionals And Institutions |
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| TopNational Health Care ReformViews Of The Health...Health As A National...Public Confidence In Health...Americans' Views Of Their...The Role Of GovernmentDiscussionNOTES |
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Historically, because of their expertise and their unique role in patient care, physicians have played a dominant role in health policy. Over the past thirty years, however, public confidence in the leaders of medicine, as well as most other major American institutions, has declined (Exhibit 5
). In the longest trend series, the proportion of Americans reporting a great deal of confidence in the leaders of medicine has declined from 73 percent in 1966 to 44 percent in 2000.18 The lowest level of public confidence occurred in 1993 (22 percent), during the debate over national health care reform.
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This decline in public confidence in the institutional leaders of medicine has not affected Americans’ high level of respect for practicing physicians, who have consistently been among the highest-ranked professionals. The past twenty-five years have witnessed no change in Americans’ assessment of the honesty and ethical standards of physicians.19
Unfortunately, there is no comparably long trend for health care institutions. A shorter series, starting in 1997, asks the public to rate the job various industries and institutions are doing for their consumers (Exhibit 6).20 Hospitals are the health care institution seen by the most people (72 percent) as doing a good job for its constituents; managed care companies, by the fewest (29 percent).
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Since 1997 there has been a twenty-two-percentage-point decline in the proportion of the public saying managed care companies are doing a good job for consumers and a twenty-point decline in positive assessments of the pharmaceutical industry. Of note, both of these declines occurred during a period when there was a major national debate about the desirability of expanding government’s regulatory role in these two areas.
The proportion of Americans who believe that the growth of managed care is a bad thing has increased from 28 percent in 1995 to 52 percent in 2000. In addition, Americans are more likely now than in 1995 to believe that the growth of managed care will harm the quality of medical care (59 percent in 2000, 39 percent in 1995) and not help to contain costs (53 percent in 2000, 31 percent in 1995).21
| Americans’ Views Of Their Own Health Care |
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| TopNational Health Care ReformViews Of The Health...Health As A National...Public Confidence In Health...Americans' Views Of Their...The Role Of GovernmentDiscussionNOTES |
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Health policy differs from many other policy areas in that the public’s views on issues are shaped at least in part by their own experiences. Two historical trends—one concerning Americans’ satisfaction with their own medical care, the other with confidence in ability to pay for a major illness—measure these experiences.
In the twenty-two years the first question has been asked, more than 80 percent of Americans have reported that they are satisfied with their last visit to a physician (Exhibit 7).22 Also, confidence in ability to pay for a major illness has improved over the years.23 Despite the increase in the number of uninsured Americans nationally, the proportion reporting such confidence has risen from 50 percent in 1978 to 67 percent in 2000. This improvement in financial confidence may be related to more comprehensive insurance and increased benefit coverage for the insured population, or it may reflect the effects of increased family incomes and assets that could be drawn upon in case of large medical bills.
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| The Role Of Government |
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| TopNational Health Care ReformViews Of The Health...Health As A National...Public Confidence In Health...Americans' Views Of Their...The Role Of GovernmentDiscussionNOTES |
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For those involved in health policy today, the public opinion environment is very different from what it was a generation ago. The period from 1964 through the early 1970s saw the enactment of Medicare, Medicaid, the War on Poverty’s health care programs, and a plethora of new government regulatory measures aimed at improving the health care system. Those decisions were made in an era when there was less widespread citizen distrust of government, a greater public willingness to have government regulate the private sector, and less public concern with the level of federal taxation.
In 1964, the year before Medicare and Medicaid were enacted, only one-fourth of Americans expressed distrust in the federal government (Exhibit 8).24 When the Clinton health plan ultimately failed in Congress in 1994, distrust of the federal government had risen fifty-four percentage points. These same years have also seen a decline in public support for government regulation of the private sector. In 1964 only 43 percent of Americans agreed with the statement that the government has gone too far in regulating business and the free enterprise system.25 This figure rose to 60 percent in 2000. Americans are clearly less willing today to see expanded government regulation in general than they were during the 1960s. Similarly, in 1961 only 46 percent of Americans thought that their federal taxes were too high.26 This figure rose to 69 percent in 1969 and stood at 63 percent in 2000.
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| Discussion |
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| TopNational Health Care ReformViews Of The Health...Health As A National...Public Confidence In Health...Americans' Views Of Their...The Role Of GovernmentDiscussionNOTES |
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A number of key questions arise from this historical review of public opinion. First, what do we know about the stability of public opinion on health care policy over the past five decades? The picture presented here is mixed. On many of the issues we examined, public opinion has been stable over long periods of time. However, in the cases of national health care reform, the priority for government action on health care, confidence in the leaders of medicine and government, and concerns about federal taxation, public opinion has changed markedly over the years. Even more dramatic is the decline of public support for both the Clinton and Truman health plans over a short period of time.
Second, what do we learn about the consistency of public opinion over these many areas of health policy? Americans hold many beliefs that are consistent with a general view of what is right or wrong about health care in the United States. However, it is striking to see how many conflicting views the public holds on health policy issues.
On the one hand, Americans report substantial dissatisfaction with our mixed private/public health care system and with the private health insurance and managed care industries. A majority of Americans indicate general support for a national health plan financed by taxpayers, as well as increased national health spending. On the other hand, these surveys portray a public that is satisfied with their current medical arrangements, in many years does not see health care as a top priority for government action, does not trust the federal government to do what is right, sees their federal taxes as already too high, and does not favor a single-payer (government) type of national health plan. Over the years these conflicts in beliefs have been difficult to resolve in legislative debates, particularly around the issues of large-scale national health care reform. This is likely to remain the case in the years ahead.
Finally, are there any lessons for better interpreting public opinion on health policies in the future? The answer from this review is clearly yes. Because Americans do hold many conflicting values and beliefs that affect their views on health care policy, it is important to be cautious in interpreting the public mood based on single, isolated public opinion questions. To be a useful guidepost for policymakers, opinion surveys require enough depth in their question wordings so that respondents can work their way through their conflicting values and beliefs to come to judgment on the issue.
| Editor's Notes |
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Bob Blendon is professor of health policy and political analysis at the Harvard School of Public Health. John Benson is managing director of the Harvard Opinion Research Program, Harvard School of Public Health.
This work was supported jointly by the Henry J.Kaiser Family Foundation and the Robert Wood Johnson Foundation. The views expressed are solely those of the authors, and no official endorsement by either sponsor is intended or should be inferred.
| NOTES |
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| TopNational Health Care ReformViews Of The Health...Health As A National...Public Confidence In Health...Americans' Views Of Their...The Role Of GovernmentDiscussionNOTES |
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- R.J. Blendon and M. Brodie, "Public Opinion and Health Policy," in Health Politics and Policy, ed. T.J. Litman and L.S. Robins (Albany, N.Y.: Delmar Publishers, 1997).
- When interpreting these findings, one should recognize that all surveys are subject to sampling error. Results may differ from what would be obtained if the whole population of adults had been interviewed. The size of the error varies with the number surveyed and the magnitude of difference in the responses to each question. Most national public opinion surveys have sample sizes of about 1,200 persons, in which the results will, with a 95 percent degree of confidence, have a statistical precision of plus or minus three percentage points of what would be obtained if the entire population had been interviewed. The sampling error for 500 respondents is plus or minus five percentage points; for 2,000 respondents, plus or minus two percentage points. Possible sources of nonsampling error include nonresponse bias, as well as question wording and ordering effects. Nonresponse produces some known biases in survey-derived estimates because participation tends to vary for different subgroups of the population. To compensate for these known biases, the sample data are typically weighted in analysis, using parameters from the most recent available census data. Other techniques, including random-digit dialing, replicate subsamples, callbacks staggered over times of day and days of the week, refusal conversions, and systematic respondent selection within households, are used in telephone surveys to ensure that the sample is representative.
- S.L. Payne, "Some Opinion Research Principles Developed through Studies of Social Medicine," Public Opinion Quarterly (Spring 1946): 93–98.
- National Opinion Research Center/Anti-Defamation League of B’Nai B’Rith (Storrs, Conn.: Roper Center for Public Opinion Research, October 1964).
- CBS News/New York Times polls (Roper Center, 12March 1980 and 8 July 1992). The complete trend also includes results from the following polls: CBS News/New York Times polls (Roper Center, 13 February 1980, 22 April 1981, 30 March 1990, 28 October 1990, 3 June 1991, 18 August 1991, 22 January 1992, 12 January 1993, and 28 March 1993); New York Times poll (Roper Center, 3 December 1995)
; and Harvard School of Public Health/International Communications Research poll (Roper Center, 16 August 2000). Question wording: "Do you favor or oppose national health insurance, which would be financed by tax money, paying for most forms of health care?" - Gallup poll (Roper Center, 24 September 1993)
; and Gallup/CNN/USA Today poll (Roper Center, 15 July 1994). - Gallup/CNN/USA Today polls (Roper Center, 22 September 1993 and 28October 1993)
; and Gallup polls (Roper Center, 24 September 1993 and 16 April 1994). - Gallup polls (Roper Center, 6March 1949 and 8 October 1950).
- Gallup/Potomac Associates polls (Roper Center, September 1964 and October 1964)
; and Harris poll (Roper Center, April 1965). - Gallup poll (Roper Center, 12 April 1946);Opinion Research Corporation poll (Roper Center, 15 March 1963)
; and Henry J. Kaiser Family Foundation/Commonwealth Fund/Louis Harris and Associates poll (Roper Center, 6 August 1993). - Harvard/ICR poll, 16 August 2000.
- Washington Post/Henry J. Kaiser Family Foundation/Harvard University poll (Roper Center, 5 July 2000). The complete trend for this question wording also includes results from Henry J. Kaiser Family Foundation/Harvard School of Public Health/Princeton Survey Research Associates polls (Roper Center, 4 November 1998, 8 October 1999, and 3 December 1999). Question wording: Do you favor or oppose "a national health plan, financed by taxpayers, in which all Americans would get their insurance from a single government plan"?
- Question wording: "Which of the following statements comes closest to expressing your overall view of the country’s health care system? On the whole, the health care system works pretty well and only minor changes are necessary to make it work better; there are some good things in our health care system, but fundamental changes are needed to make it work better; the health care system has so much wrong with it that we need to completely rebuild it."
- Gallup/CNN/USA Today polls (Roper Center, 8 January 1993, 10 January 1997, and 7 January 2000).
- American Medical Association poll (Roper Center, 24 July 1981)
; and Harvard/ICR poll, 16 August 2000. - Question wording: "We are faced with many problems in this country, none of which can be solved easily or inexpensively. I’m going to name some of these problems, and for each one I’d like you to tell me whether you think were spending too much money on it, too little money, or about the right amount. Are we spending too much, too little, or about the right amount on... improving and protecting the nation’s health?"
- Harris polls (Roper Center, 22 January 1993, 4 March 1993, 28 April 1993, 24 June 1993, 13 August 1993, 1 October 1993, 11 November 1993, 20 December 1993, 2 February 1994, 4 April 1994, 23May 1994, 17 September 1994, 8November 1994, 9 December 1994, 8 June 1995, 26 October 1995, 9 January 1997, 5 June 1997, 20 August 1997, 15 October 1997, 14 January 1998, 18 February 1998, 27 April 1998, 17 July 1998, 12 August 1998, 9 September 1998, 11 November 1998, 7 January 1999, 11 February 1999, 8 April 1999, 14 May 1999, 10 June 1999, 12 August 1999, 17 September 1999, 22 October 1999, 2 December 1999, 6 January 2000, and 8 September 2000); for February–July 2000, Harris poll (New York: Harris Interactive, 25 July 2000). Question wording: "What do you think are the two most important issues for the government to address?"
- Harris poll (New York: Harris Interactive, 26 January 2000). Question wording: "As far as people in charge of running medicine are concerned, would you say you have a great deal of confidence, only some confidence, or hardly any confidence in them?"
- Gallup polls (Roper Center, 11 June 1976, 19 August 1977, 24 July 1981, 20May 1983, 12 July 1985, 23 September 1988, 8 February 1990, 16 May 1991, 26 June 1992, 19 October 1995, and 4 November 1999)
; and Gallup/CNN/USA Today polls (Roper Center, 19 July 1993, 23 September 1994, 9 December 1996, 6 November 1997, and 23 October 1998). Question wording: "Please tell me how you would rate the honesty and ethical standards of people in these different fields [medical doctors]—very high, high, average, low or very low." - Question wording: "Do you think [each of these industries] generally do a good or bad job of serving their consumers?"
- Harris poll (New York: Harris Interactive, 19 July 2000).
- Question wordings: "Thinking about the last time you saw a medical doctor about yourself, would you say you were very, fairly, not too, or not at all satisfied with the medical care you received?" (1978–1987); and "Thinking about your most recent visit to a medical doctor, would you say you were very satisfied, somewhat satisfied, not very satisfied, or not at all satisfied with the medical care you received?" (1990–2000).
- Question wording: "How confident are you that you would have enough money or health insurance to pay for a major illness? Are you very confident, somewhat confident, not very confident, or not at all confident?"
- National Election Surveys, "The NES Guide to Public Opinion and Electoral Behavior," <www.umich.edu/~nes/nesguide/toptable/tab5a_1.htm> (14 September 2000), for 1958–1994, 1996, and 1998; Washington Post/Kaiser/Harvard polls (Roper Center, 28 November 1995 and 30 June 1999)
; and ABC News/Washington Post poll (Roper Center, 30 March 2000). Question wordings: "How much of the time do you think you can trust the government in Washington to do what is right: just about always, most of the time, or only some of the time?" (1958–1994, 1996, 1998, 2000) ; and "How much of the time do you think you can trust the government in Washington to do the right thing: just about always, most of the time, or only some of the time?" (1995, 1999). - Gallup/Potomac Associates poll (September 1964); CBS News/New York Times polls (Roper Center, 8 January 1978, 7 November 1980, and 22 April 1981)
; Council on Excellence in Government/Hart and Teeter Research Companies poll (Roper Center, 16 March 1995) ; Pew Center for the People and the Press/Princeton Survey Research Associates poll (Roper Center, 25 September 1997); Washington Post/Kaiser/Harvard poll (Roper Center, 10 August 1998) ; and NPR/Kaiser/Kennedy School poll (26 May 2000). Question wording: (Agree/disagree) "The government has gone too far in regulating business and interfering with the free enterprise system." - Gallup polls (Roper Center, 16 February 1956, 6 April 1957, 4 March 1959, 10 February 1961, 8 February 1962, 11 January 1963, 28 February 1964, 10 February 1966, 9 March 1967, 12March 1969, 16 February 1973, 14 May 1982, 7 June 1985, 8 March 1990, 28March 1991, 26 March 1992, 29March 1993, and 16 December 1994)
; and Gallup/CNN/USA Today polls (Roper Center, 9 April 1996, 24 March 1997, 17 April 1998, 6 April 1999, and 7 April 2000). Question wording: "Do you consider the amount of federal income tax you have to pay as too high, about right, or too low?" - When interpreting these findings, one should recognize that all surveys are subject to sampling error. Results may differ from what would be obtained if the whole population of adults had been interviewed. The size of the error varies with the number surveyed and the magnitude of difference in the responses to each question. Most national public opinion surveys have sample sizes of about 1,200 persons, in which the results will, with a 95 percent degree of confidence, have a statistical precision of plus or minus three percentage points of what would be obtained if the entire population had been interviewed. The sampling error for 500 respondents is plus or minus five percentage points; for 2,000 respondents, plus or minus two percentage points. Possible sources of nonsampling error include nonresponse bias, as well as question wording and ordering effects. Nonresponse produces some known biases in survey-derived estimates because participation tends to vary for different subgroups of the population. To compensate for these known biases, the sample data are typically weighted in analysis, using parameters from the most recent available census data. Other techniques, including random-digit dialing, replicate subsamples, callbacks staggered over times of day and days of the week, refusal conversions, and systematic respondent selection within households, are used in telephone surveys to ensure that the sample is representative.
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 R. G A Feachem, N. K Sekhri, K. L White, J. Dixon, D. M Berwick, and A. C Enthoven Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente Commentary: Funding is not the only factor Commentary: Same price, better care Commentary: Competition made them do it BMJ, January 19, 2002; 324(7330): 135 - 143. [Abstract] [Full Text] [PDF]
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D. C. Leach Competence Is a Habit JAMA, January 9, 2002; 287(2): 243 - 244. [Full Text] [PDF]
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M. A. Peterson From Trust to Political Power: Interest Groups, Public Choice, and Health Care Journal of Health Politics Policy and Law, October 1, 2001; 26(5): 1145 - 1164. [PDF]
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 E. D. Kinney The Brave New World of Medical Standards of Care J. Law Med. Ethics, September 1, 2001; 29(3-4): 323 - 334. [PDF]
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